Provider Demographics
NPI:1225423916
Name:NATIVE PRIDE HOME CARE LLC
Entity Type:Organization
Organization Name:NATIVE PRIDE HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:PHETVISAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-357-2713
Mailing Address - Street 1:PO BOX 36409
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27416-6409
Mailing Address - Country:US
Mailing Address - Phone:800-357-2713
Mailing Address - Fax:
Practice Address - Street 1:619 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAURINBURG
Practice Address - State:NC
Practice Address - Zip Code:28352-4535
Practice Address - Country:US
Practice Address - Phone:800-357-2713
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-31
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC4468253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCHC4468Medicaid